Ralls Nursing Home

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 42% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 46 beds and averages 33.7 residents a day — about 73% occupied, or roughly 12 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.29 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 1.98 hrs/resident/day on weekends vs 2.44 on weekdays — 19% thinner on weekends. RN hours go from 0.33 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 19 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-01-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN A, CNA B and CNA C forced Resident #1 to leave the dining room and go to bed when they dragged Resident #1 with a blanket to her room.LVN A, CNA B and CNA C made verbal comments about Resident #1 on front of and to Resident #1 mind your own business, calling to find another place for her to live, why haven't they made her move yet.The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/2026. The facility had corrected the noncompliance before the survey began on 01/12/2026.These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.Findings include:Record review of Resident #1's face sheet, dated 1/13/26…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2026-01-14 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement written policies and procedures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of known source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Administrator for 1 of 8 residents (Resident #1) reviewed for abuse. The facility failed to follow their policy for abuse and neglect when LVN A, CNA B and CNA C failed to report an incident with Resident #1 for 2 days and the ADON and BOM failed to immediately report Resident #1's allegation of abuse to the ADM prior to investigation. The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/2026. The facility had corrected the noncompliance before the survey began on 01/12/2026.These failures could affect all residents by…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2026-01-14 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to the abuse coordinator, the facility Administrator for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to follow their policy for reporting abuse and neglect when LVN A, CNA B and CNA C did not report an incident with Resident #1 for 2 days. LVN A, CNA B and CNA C continued to work with Resident #1 because they failed to report the abuse to the ADM. The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/2026. The facility had corrected the noncompliance before the survey began on 01/12/2026.These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.Findings include:Record review of Resident #1's face sheet, dated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-07-18 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. The noncompliance was identified as PNC. The IJ began on 07/13/25 and ended on 07/14/25. The facility had corrected the noncompliance before the survey began on 07/15/25. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include:Record review of Resident #1's face sheet, dated 07/17/25, revealed an [AGE] year-old-female who was originally admitted to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-07-18 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement written policies and procedures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of known source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Administrator for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. The noncompliance was identified as PNC. The IT began on 07/13/25 and ended on 07/14/25. The facility had corrected…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-07-18 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to the abuse coordinator, the facility Administrator for 2 of 5 residents (Resident #1) reviewed for abuse.The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 on 7/13/25 at 6:07 PM when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. LVN D remained working at the facility for 6 hours the remainder shift on 7/13/25 after the incident and had direct contact with Resident #1.The noncompliance was identified as PNC. The IJ began on 07/13/25 and ended on 07/14/25. The facility had corrected the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Immediate jeopardy · Kcited before2024-06-10 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents had the right to be free from sexual abuse for 3 (Resident #3, Resident #4 and Resident #6) of 9 residents reviewed for abuse. 1. The facility failed to put protective measures in place on 05/11/24 to protect Resident #4 from sexual abuse after knowing Resident #2 had displayed inappropriate sexual behavior with Resident #3. 2. The facility failed to put protective measures in place on 06/02/24 to protect Resident #3 in place from sexual abuse after knowing Resident #5 had a history of inappropriate sexual behavior. 3. The facility failed to put protective measures in place on 06/02/24 to protect Resident #6 in place from sexual abuse after knowing Resident #5 had a history of inappropriate sexual behavior. On 06/07/24 at 5:00 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/09/24 at 3:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2024-06-10 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse and neglect for 4 (Resident #1, Resident #3, Resident #4, and Resident #6) of 9 residents reviewed for abuse and neglect. The facility failed to implement their abuse and neglect policy when: 1. The facility failed to investigate the fall incident that occurred with Resident #1 while in the care of CNA E on 05/30/24. CNA E failed to notify the nurse of the fall. Resident #1 sustained a hip fracture. 2. The facility failed to report to the state agency and investigate a sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3. 3. The facility failed to report to the state agency and investigate a sexual incident that occurred on 05/11/24 between Resident #2 and Resident #4. 4. The facility failed to notify Family Member C of the inappropriate sexual incident that involved Resident #3. 5. The facility failed to report to the state agency and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-05-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 (Residents #1) residents reviewed for adequate supervision and prevention of accidents. The facility staff (Administrator and DON) failed to adequately address Resident #2's ongoing behavior of entering Resident #1's room. The facility (Administrator and DON) failed to address resident #2's ongoing physical and verbal behavior with appropriate interventions. These failures to put supervision measures in place could result in harm to Resident #2 and the remaining residents in the facility. The findings included: Record review of Resident #1's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include Cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-01-14 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure of 5 of 8 residents (Residents #2, #3, #4, #5, and #6) were free from misappropriation of personal property.The facility did not prevent RN D from taking residents #2, #3, #4, #5 and #6's personal property. This failure could place residents at risk for decreased quality of life and distrust for the staff.Findings include:Record review of Resident #2's face sheet, dated 01/14/2026, revealed a [AGE] year-old female who was admitted to facility on 01/13/25 with diagnosis that included bilateral hearing loss (reduction of hearing ability to both ears), paraplegia (paralysis affecting the lower half of the body), major depressive disorder (persistent sadness, loss of interest in daily activities), anxiety disorder (mental health condition characterized by persistent, excessive fear and worry), age-related cataract of the left eye (clouding of the eye's natural lens), and bilateral optic atrophy (damage to the visual pathway).Record…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-26 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observations, interviews and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 1 resident (Resident #1), reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors when MA B administered Tegretol 200mg (prescribed for seizures, bipolar disorder, and nerve pain), Lipitor 40mg (prescribed to lower cholesterol), Baclofen10mg (muscle relaxer), Metoprolol 25mg (prescribed to lower blood pressure), Neurontin 300mg (prescribed for seizures and nerve pain), Quetiapine Fumarate 200mg (medication prescribed for bipolar disorder and schizophrenia) to Resident #1 on 10/13/25, when these medications were prescribed to another resident. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician.Findings Included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-16 · tag F0565 — failed to support the resident council — pattern
  Honor the resident's right to organize and participate in resident/family groups in the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 14 of 35 confidential residents who were reviewed for resident council.The facility failed to provide a private space for resident council meetings.Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 14 of 35 confidential residents who were reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents at risk of not being able to voice concerns due to a lack of privacy. Findings include: Observation of the dining room on 9/15/25 revealed multiple staff and residents coming in and out of the dining room while the Resident Council meeting was in session. In a confidential group interview on 9/15/25 14 alert and orientated residents, who attended resident council, stated resident council was always held in the dining room. They stated staff came in and out…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-16 · tag F0585 — failed to handle grievances — pattern
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 14 of 35 confidential residents reviewed for resident rights. The facility failed to ensure 14 confidential residents were provided, the Grievance Procedure, information in regard to who the facilities' grievance officer was, their contact information, and how to file an anonymous grievance. Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 14 of 35 confidential residents reviewed for resident rights. The facility failed to ensure 14 confidential residents were provided, the Grievance Procedure, information in regard to who the facilities' grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included:…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-16 · tag F0727 — failed to provide required RN coverage — pattern
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 3 of 30 days (8/30/2025, 9/4/2025, and 9/13/2025) reviewed for RN coverage.- The facility failed to ensure that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 8/30/2025, 9/4/2025, and 9/13/2025. This failure could place residents at risk of not having adequate qualified personnel in case of a health crisis. Findings include:Record review of facility document titled Punch details- Report, revealed on 8/30/2025 the facility had RN coverage for 3.5 hours. On 9/4/2025 the facility had RN coverage for 7.02 hours. On 9/13/2025 the facility did not have any documented RN coverage. During an interview on 9/16/2025 at 12:29pm with the DON she stated she was responsible for ensuring the facility had RN coverage. She stated one of those days, the RN for that day was delayed at the airport and was unable to provide coverage for the rest of the day. She stated on 9/13/2025 she had been sick…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-09-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure frozen pork was not stored above ready-to-eat foods in the freezer. The facility failed to ensure the window seal directly above the kitchen sink was free of dirt build-up and grime.The facility failed to ensure a container of ice used to prepare drinks for lunch, did not have a scoop stored inside of it.The facility failed to ensure all condiments had expiration or use-by dates. The facility failed to ensure a cleaning schedule was followed and monitored. These failures could place residents who received meals and/or snacks from the kitchen at risk of food contamination and food borne illness.Findings included: During the initial tour and observation of the kitchen on 09/14/25 at 11:20 AM the following were revealed: *Two packages of uncooked pork loin stored in a kitchen freezer above ready-to-eat and prepared…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-16 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 16 (Resident # 37) residents reviewed for abuse and neglect.- The facility did not report to the State Agency when Resident #37, was found unresponsive and not breathing in her room on 8/3/2025. On 8/9/2025 the DON was made aware that EMS reported food in Resident #37 airway, as a possible cause for Resident #37's medical emergency. This failure could place residents at risk of abuse, neglect and eliminate the opportunity for a timely investigation by the State Agency. Findings include: Record review of Resident #37s…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-20 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 3 residents (Residents #32) reviewed for infection control. The facility failed to ensure CNA A utilized proper hand hygiene during incontinence care for Resident #32. This failure could place residents at risk for infection and cross contamination. The findings include: Record review of Resident #32's undated face sheet revealed an [AGE] year-old male originally admitted on [DATE]. Resident #32 had a medical history of malignant neoplasm of prostate (an abnormal growth of tissue that can spread into nearby tissues and other parts of the body), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and atrial fibrillation (a common type of irregular heart rhythm). Record review of Resident #32's quarterly MDS assessment dated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-20 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, on facility grounds in 1 of 2 parking lots (front entrance parking lot) in that: The facility failed to ensure the trash was emptied into the dumpster for five hours. This failure could attract unwanted pests and cause the facility to have an unsightly appearance. The findings included: On 8/19/24 at 9:45 AM, an observation was made of a trashcan located near the front entrance in the front parking lot. The trashcan was observed to be full of trash which prevented the lid from closing. The trash items observed were Styrofoam food containers and cups, fast food bags, and other miscellaneous trash. On 8/19/24 at 12:29 PM, an observation was made of a trashcan located near the front entrance in the front parking lot. The trashcan was observed to be full of trash which prevented the lid from closing. The trash items observed were Styrofoam food containers and cups, fast food bags, and other miscellaneous trash. On 8/19/24 at…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-06-10 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administer of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 5 of 9 residents (Residents #2, #3, #4, #5 and #6) reviewed for abuse and neglect. 1. The facility failed to report a sexual incident which occurred on 05/10/24 between Resident #2 and Resident #3. 2. The facility failed to report a sexual incident which occurred on 05/11/24 between Resident #2 and Resident #4. 3. The facility failed to report a sexual incident which occurred on 06/02/24 between Resident #5 and Resident #3. 4. The facility failed to report a sexual…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$303,179 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $8,281 — penalty dated 2026-01-14
• $12,740 — penalty dated 2026-01-14
• $16,543 — penalty dated 2025-07-18
• $203,177 — penalty dated 2024-06-10
• $62,438 — penalty dated 2024-05-09
• Medicare payment denial — starting 2024-07-12 for 11 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

CMS files one row per role, so the 24 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in TX